Pocahontas Center

Inspectors wroteBased on staff interview and record review, the facility failed to notify a resident's physician and responsible party of a significant change when resident attempted elopement from the facility. This was found while investigating a complaint. Resident identifier: #48. Facility Census: 62. Findings Included:a) Review of documents including resident's progress notes, care plan and incident report log had no record of resident's attempted elopement, contact to resident's physician or Resident #48's responsible party.b) Interview with Licensed Practical Nurse # 46 on 02/02/26 at 12:19 PM, acknowledged the incident occurred and that she reported it to her Director of Nursing. c) Interview with Director of Nursing #40 on 02/02/26 at 3:19 PM who acknowledged the attempted elopement occurred on 01/17/26. [...]

Inspectors wroteBased on record review, observation. and staff interview the facility failed to ensure Resident #8 was served liquid in a form which met his individualized needs. Resident # 8 was ordered and care planned to receive nectar thickened liquids however during the noon time meal on 12/16/25 the resident was served regular consistency milk and regular consistency coffee. The resident did drink the thin liquids and experienced coughing. This was a random opportunity for discovery and was true for Resident #8. The State Agency (SA) determined the facility's failure to serve Resident #8 with nectar thickened liquids place him at immediate risk for serious harm and/or death. Consuming thin liquids when you have been assessed to need a thicker consistency can create an immediate risk for choking, aspiration, and/or death. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #46 was transferred to from her geri chair to her bed in a manner which was not safe for her. Resident #46 was found to be totally dependent on staff for transfers. The staff were to utilize a total mechanical lift to transfer the resident from the chair to the bed and from the bed to the chair. Two (2) nurse aides were observed taking Resident #46 into her room. The surveyor stood outside the resident door and kept the room under constant sight. When the nurse aides emerged from the room the resident was in the bed. When asked how they transferred the Nurse Aide, stated I stood her up and pivoted her to bed. She confirmed she did not use a lift and no lift was observed in the room. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure sufficient nursing staff across all shifts. This was true for 18 of 45 days reviewed under the care area of staffing. Facility Census: 59. Findings Include: a) Staffing On 09/30/2025 at 2:00 PM, 45 daily nurse staff postings were reviewed. The minimum staffing requirement is 2.25. The review found the following days did not meet the minimum of nursing hours per patient days (NHPPD): 09/21/24 2.1104/19/24 2.0904/20/25 2.2005/17/25 2.2005/24/25 1.4805/25/25 2.1505/31/25 2.1806/01/25 1.8806/07/25 1.6406/21/25 1.8206/22/25 2.0106/23/25 1.9506/25/25 2.2106/27/25 2.0806/28/25 1.9306/29/25 2.0706/30/25 2.2007/05/25 2.05 On 09/30/25 at 4:40 PM, the Administrator and the Regulatory Compliance Advisor #73 confirmed the minimum NHPPD were not met.

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete daily staff postings. This was true for four (4) of 45 daily staff postings reviewed. Facility Census: 59. Findings Include: a) Daily Staff Postings On 09/30/2025 at 2:00 PM, a review of daily staff postings was completed. The following days did not include the census: --05/10/25 day shift, evening shift, night shift--05/22/25 day shift, evening shift, night shift --06/06/25 day shift, evening shift, night shift--06/24/25 night shift On 09/30/25 at 4:40 PM, the Administrator and Regulatory Compliance Advisor #73 confirmed the daily staff postings did not list the census number.

Inspectors wroteBased on staff interview, resident interview and record review, the facility failed to ensure the residents knew where the ombudsman's contact information was posted and the residents were informed of their right to formally complain to the Office of Health Facility Licensure and Certification (OHFLAC) about the care they are receiving. These failed practices had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 59.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide activities of daily living for dependent residents, #6 and #11. This was true for two (2) of four (4) residents reviewed under the care area of activities of daily living. Resident Identifiers: #6 and #11. Facility Census: 59. Findings Include:a) Resident #6On 09/24/25 at 9:30 AM, a record review was completed for Resident #6. The review of showers was from 08/24/25 through 09/24/25. The care plan indicated the resident was dependent for showers. The following showers were documented for 08/24/25 through 08/31/25:--08/29/25--08/30/25 The resident did not have a shower for five (5) days between 08/24/25 through 08/29/25. There were no refusals documented within this timeframe. The following showers were documented from 09/02/25 through 09/11/25. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Physician Orders for Scope of Treatment (POST) form was signed by a resident's Medical Power of Attorney (MPOA), a Beneficiary Notification Review was signed by a resident's Health Care Surrogate (HCS), accurate documentation was charted in the patient's medical record for a resident without an amputation and a correct diagnosis for a resident's medication. These failed practices had the potential to affect more than a limited number of resident's. Resident Identifiers: #60, #70, #71 and #5. Facility Census: 59.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to thoroughly and accurately explain the binding arbitration agreement. This failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 59. Findings Included: a) The facility's Voluntary Binding Arbitration Agreement stated the agreement waives the resident's right to trial in court by judge or jury. Arbitration is a complete substitute for a trial by jury as stated in the facility's agreement. b) On 09/29/2025 at 01:28 PM, the Administrator was interviewed concerning the arbitration agreement. The Administrator reported it was fully voluntary and you had thirty (30) days to change your mind. The administrator stated we have mediation before you go to trial. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide a dignified experience for Resident #21 while receiving medical care at the nurses' station, a sleeping experience for Resident #46. This was true for one (2) of three (3) residents reviewed under the care area of accidents for Resident #21 and random opportunities for discovery for Resident #46. Resident Identifiers: #21 and #46. Facility Census: 59. Findings Include: a) Resident #21 On 09/29/25 at 1:30 PM, a review of an anonymous complaint dated 07/05/25 was completed. The review found the resident had sustained an unwitnessed fall which resulted in a laceration to the back of the head with a large hematoma. A change in condition was completed on 07/02/25 at 6:17 AM. The facility physician was notified and advised the staff he would be coming to the facility to evaluate the laceration and hematoma. [...]

Inspectors wroteFacility Failed to ensure resident was invited to participate in care planning for his own care. Resident #1009/23/2025 2:41 PM Resident reported he is not invited to his care plan meetings and he has never attended them. 10/24/2025 4:01 PMInterview with Social Worker who reported resident #10 does not receive invites to his care plan meetings. She had no documentation that he was notified of the meetings or that he attended. She stated he does not like to leave his room often. She stated his Medical Power of Attorney is invited but does not attend and does not respond.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, homelike environment for Resident #46. This was a random opportunity for discovery. Resident Identifier: #46. Facility Census: 59. Findings Include:a) Resident #46On 11/04/25 at approximately1:30 PM, an observation was made of Resident #46's night stand. The night stand had the wood peeled off, exposing particle board. On 11/04/25 at 3:10 PM, Regulatory Compliance Advisor #73 confirmed the wood had peeled off the night stand exposing particle board. Regulatory Compliance Advisor #73 stated, we will get a new one.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an incident was reported for a resident who obtained a hematoma to the head following a transfer with a lift requiring staff education. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #37. Facility Census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an investigation was completed accurately and thoroughly for a Facility Reported Incident (FRI) for an allegation of abuse. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #29. Facility Census: 59.

Inspectors wroteBased on record review and staff interview, the facility failed ensure Resident #71 was permitted to return to the facility after hospitalization. This was true for one (1) of one (1) residents reviewed under the care area of Discharges. Resident Identifier: #71. Facility Census: 59. Findings Include:a) Resident #71On 11/03/25 at approximately 9:15 AM, a complaint was reviewed regarding Resident #71 being denied readmission after a hospitalization due to behaviors, a urinary tract infection and severe dehydration. The resident was sent to an acute care facility on 09/12/25. Based on the hospital history and physicaldated 09/18/25 at 10:27 AM, the resident was admitted to a medical unit until a bed became available on the psychiatric unit. The resident continued to have behaviors after intravenous fluids (IVFs) and an antibiotic had been administered. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate Minimum Data Set (MDS) for Resident #9 regarding hospice care. This was true for one (1) of one (1) residents reviewed under the care area of hospice. Resident Identifier: #9. Facility Census: 59. Findings Include: a) Resident #9 On 09/24/25 at 11:00 AM, a record review was completed for Resident #9. The review found the MDS with an assessment reference date (ARD) of 07/30/25. The resident was placed under hospice care on 07/23/25. However, the MDS section O K1., hospice care was marked no for receiving hospice care. On 09/24/25 at 11:06 AM, the Corporate Registered Nurse (RN) #72 confirmed the MDS was incorrect.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a complete and accurate care plan for Resident #9. This was true for one (1) of one (1) residents reviewed under the care area of hospice care. Resident Identifier: #9. Facility Census: 59. Findings Include:a) Resident #9On 09/24/25 at 8:55 AM, a record review was completed for Resident #9. The review found the care plan had not been developed completely under multiple focus areas, goals and interventions. The following areas of the care plan were left blank:--Under the focus area of resistive to care related to cognitive loss/dementia, the intervention observe for pain. Attempt non-pharmacologic interventions to alleviate pain (blank) and document effectiveness. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to input a physician's order for Resident #9 regarding hospice services and follow physician's orders for Resident #26 and #27 regarding late medication. This was true for three (3) of 20 residents reviewed during the survey process. Resident Identifiers: #9, #26 and #27. Facility Census: 59. Findings Include:a) Resident #9On 09/24/25 at approximately 1:00 PM, a record review was completed for Resident #9. The review found the resident was placed under hospice services on 07/31/25. However, a physician's order was not input until 09/24/25. On 09/24/25 at 1:30 PM, Corporate Registered Nurse (RN) #72 confirmed the resident was under hospice services as of 07/31/25 and the physician's order was input on 09/24/25.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure nurse aide performance reviews were completed annually. This was true for three (3) of five (5) nurse aides' annual performance reviews during the survey process. Facility Census: 59. Findings Include: a) Performance Review On 09/30/25 at 3:45 PM, a review of the five (5) nurse aides (Nas) performance reviews was completed. The review found three (3) of the five (5) performance reviews were not completed. The following were incomplete: --NA #50 due 09/18/25--NA #46 due 06/27/25--NA #38 due 07/25/25 On 09/30/25 at 4:40 PM, the Administrator and the Regulatory Compliance Advisor #73 confirmed the performance reviews were not completed.

Inspectors wroteBased on observation and staff interview, the facility failed to serve food at an appetizing and palatable temperature for Resident #46. This was a random opportunity for discovery and was true for Resident #46. Resident Identifier: 46. Facility Census: 59. On 11/03/25 at 12:44 PM an observation of Resident #46 found the resident was in her bed with her head at the foot of the bed and the bed wedge was kicked out to the side of her bed. Nurse Aide #35 was asked how much the resident had eaten she stated, I dont know I was not the one who feed her. She said, let me see. She then was asked if her dirty tray was on the cart on the hall, she said no we do not put the dirty ones back on that cart we put them somewhere different. She then opened the cart and stated, Oh she hasn't been feed yet and neither has her roommate. She stated, I will feed her now. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an infection control program during medication administration for Resident #19. This was true for one (1) of five (5) residents reviewed under the care area of medication administration. Facility Census: 59. Findings Include: a) Resident #19 On 11/04/25 at 8:24 AM, medication administration completed by Graduate Practical Nurse (GPN) #14 for Resident #19. While preparing the medication for administration, GPN #14 touched the medication cart trash can lid two times. GPN #14 did not complete hand hygiene after touching the medication cart trash can lid two times. On 11/04/25 at 9:10 AM, GPN #14 confirmed hand hygiene should have been completed after touching the trash can lid. On 11/04/25 at 9:20 AM, the Director of Nursing (DON) was notified. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents were free from abuse from other residents. Beginning on 04/19/23 Resident #20 began displaying physical, verbal and sexually abusive behaviors towards residents and staff. A review of the record found at least 20 noted incidents of such behavior. The abusive behavior was not consistently reported as required, the physician and responsible party was not consistently notified, the victims were not consistently identified, and interventions were not consistently put into place to prevent the abuse from reoccurring. Resident #20 still currently resides at the facility and has had documented episodes of said behaviors as recent as 07/05/24. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident environment of which it had control was as free from accident hazards as possible. The facility failed to maintain the dryer in a safe manner. This failed practice has the potential to affect all residents currently residing in the facility. Facility census: 67.

Inspectors wroteBased on facility record review and staff interview the facility failed to have Registered Nurse coverage for eight (8) consecutive hours daily. This was discovered through the long term care survey process and has the potentios to affect all residents currently resding in the facility. Facility Census: 67. Findings Include: a) No RN coverage. During a review of the staffing posting forms on 07/29/24 at approximately 6:30 PM the following staffing form for 03/18/23 did not have an RN on staff for the day. It was further observed that 04/09/23 had only 7.83 of the required eight (8) hours of RN coverage. During an interview with the Scheduler #88 on 07/30/24 at approximately 8:55 AM she agreed, there was no RN coverage for 03/18/23 and only 7.83 of the required eight (8) hours for 04/09/24.

Inspectors wroteBased on facility record review and staff interview the facility failed to complete staff evaluations. This was true for one (1) of five (5) staff evaluations reviewed during the long term care process. Identifier: Certified Nursing Assistant (CNA) # 61. Facility Census: 67. Findings Included: a) CNA #61 During a record review of the CNA's evaluation it is identified that CNA #61 was hired on 05/09/24 and the evaluation was completed by the DON on 06/27/24. However a small yellow post-it note was identified to be covering the signature line for CNA #61 and it stated (typed as written) employee missed to go over review with the [DON name] During an interview with the Scheduler #88, she agreed that the evaluation was incomplete and should have been completed with the staff member when she had returned to the facility.

Inspectors wroteBased on facility record review and staff interview the facility failed identify the required Certified Nurse Aide (CNA)/nursing competencies to meet the resident populations care needs. This was a random opportunity for discovery during the CNA/nursing competency review of the long term care survey process. This had the ability to affect more than a limited number of residents. Facility Census: 67. Findings Include: a) Facility assessment During a review of the facility assessment on 08/31/24 at approximately 10:30 AM it was identified the facility centered care areas of the resident population is outlined. It is further identified on page 20 of 43 of the facility assessment, under II. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement the policy and procedure entitled, Abuse Prohibition. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: Resident #20, Resident #22, Resident #62. Facility census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to report to the appropriate state agencies as listed in the policy and procedure entitled, Abuse Prohibition. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: Resident #20, Resident #22, Resident #62. Facility census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to imvestigate allegations of abuse as listed in the policy and procedure entitled, Abuse Prohibition. This failed practice has the potential to affect more than a limited number of residents. Resident identifier: Resident #20, Resident #22, Resident #62. Facility census: 67.

Inspectors wroteBased on observation and staff interview the facility failed to act in accordance with currently accepted professional principles in accordance with expired medical supplies. This failed practice has the potential to affect more than a limited number of residents currently residing at the facility. Facility Census:

Inspectors wroteBased on observation and staff interview the facility failed to prevent infections through indirect contact transmission by storing clean resident clothing in the chemical closet of the laundry room. This failed practice has the potential to affect more than a limited number of residents. Facility census: 67.

Inspectors wroteBased on observation and staff interview the facility failed to provide a dignified dining experience for a resident while assisting them to eat. This was a random opportunity of discovery during the long term care survey process and was true for Resident #7. Resident Identifier: #7. Facility Census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #60 had documentation related to the provision of information provided to Resident #60 and/or Resident #60's representative related to advanced directives. This was true for 1 (one) of 7 (seven) residents reviewed in the Long Term Survey Process. Resident identifier: Resident #60. Facility Census: 67.

Inspectors wroteBased on observation and staff interview the facility failed to provide the Resident the right to a safe, clean, comfortable and homelike environment. Resident Identifier: Room #A1-1 and B9-1. Facility Census: 67 Findings Include: a) Room A1-1 On 07/29/24 at 9:56 AM, it was observed that room A1-1 had two (2) soiled privacy curtains in the room. One had a brown substance on it and the other had a brown substance and red spots. On 07/30/24 at 10:21 AM, it was observed and noted that the curtains were still in the room. This was confirmed with Registered Nurse #28 and Corporate Clinical Lead on 07/30/24 at 10:03 AM. [...]

Inspectors wroteBased on medical record review and staff interviews the facility failed to notify to the ombudsman of a resident transfer/discharge to the hospital. This was true for one (1) of three (3) residents reviewed for hospitalizations during the long term care survey process. Resident Identifiers: Resident #68. Facility Census: 67.

Inspectors wroteBased on medical record review and staff interviews the facility failed to notify resident representatives of the bed hold policy at the time of transfer/discharge. This was true for two (2) of two (2) residents reviewed for transfers/discharges during the long term care survey process. Resident Identifiers: Resident #68 and Resident #51. Facility Census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to coordinate with the appropriate State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs when completing/revising a Pre-admission Screening and Resident Review (PASSR). This was true for three (3) of three (3) residents who had their PASSR's reviewed during the long term care survey process. Resident Identifiers: 57, 43, 16. Facility Census: 67. Findings Include: a) Resident #57 On 07/30/24 at 11:00 AM record review found Resident #57 had the following medical diagnosis: [...]

Inspectors wroteBased on record review and staff interview the facility failed to monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder. This was true for 1 (one) of 1 (one) resident's reviewed for the Long Term Care Survey Process. Resident identifier: Resident #16. Facility census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to revise care plan to be resident specific when the residents care needs changed. This was true for two (2) of 23 sampled residents reviewed during the long term care survey process. Resident Identifier: #25 and #44. Facility Census: 67 Findings Include: a) Resident #25 On 07/31/24 at 2:58 PM record review of the comprehensive care plan for Resident #25 found that it had not been revised when they no longer was insulin dependent. The care plan (created on 11/16/23) focus for diabetes states Resident #25 is insulin dependent when in fact her Lantus insulin was discontinued on 07/25/24. This was confirmed with the Corporate Clinical Lead #75 on 07/31/24 at 3:30 PM who agreed the care plan should have been revised accordingly. b) Resident #44 On 07/29/24 at 9:45 AM observation shows Resident #44 is a frail, small resident. [...]

Inspectors wroteBased on record review and staff interview the facility failed to follow Physician orders related to reporting elevated blood glucose levels. This was a random oppurtunity for discovery and was true for Resident #25. Resident Identifier: #25 Facility Census: 67 Findings Include: a) Resident #25 On 07/31/24 at 4:16 PM record review found, Resident #25 has the following orders: Monitor blood sugars twice weekly at 6:30 am. Notify Physician if less than (<) 60 or greater than (>)300 one time a day every Wednesday and Sunday for signs and symptoms of hyper or hypo glycemia diaphoresis changes of level of conscience. Documentation shows the following dates the blood glucose was out of range and not reported to the physician as ordered. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure a resident who is incontinent of bladder received timely appropriate incontinence care. This was true for 1 (one) of 1 (one) residents reviewed for the Long Term Care Survey Process. Resident identifer: Resident #60. Facility Census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder. This was true for 1 (one) of 1 (one) resident's reviewed for truama informed care during the Long Term Care Survey Process. Resident identifier: Resident #16. Facility census: 67.

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to provide medically necessary social services in the area of discharge planning and appointment of a healthcare decision maker. This was a random opportunity for discovery and true for resident #62 and #48. Facility Census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to monitor behaviors for a resident receiving psychotropic medication. This was true for 1 (one) of five (5) resident's reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident identifier: Resident #16. Facility Census: 67.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #16's medical record was complete and accurate. This was true for 1 (one) of 23 sampled residents reviewed during the Long Term Care Survey Process. Resident identifier: Resident #16. Facility Census: 67.

Inspectors wroteBased on facility record review, observation and staff interview the facility failed to post the staffing posting form in a prominent location and failed to complete information on the form accurately. This was discovered through the long term care survey process and had the ability to affect more than a limited number of residents. Identifiers: Staffing Posting location, missing and inaccurate data. Facility Census: 67.

Inspectors wroteBased on record review, staff interview, the facility failed to implement a comprehensive care plan related to the need for isolation during an active episode of extended spectrum beta-lactamase (ESBL) infection. Resident identifiers: #6, #34 and #5. Facility census: 65.

Inspectors wroteBased on record review, facility documentation, and staff interview the facility failed to implement an infection control program designed to reduce the transmission of resistant organism (Multidrug-resistant organism (MDRO) transmission. This failed practice had potential to affect a more than a limited number of residents who currently reside at the facility. Resident identifiers: #5, #54, and #6. Facility census 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two (2) of 16 residents reviewed during the long term care survey, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to follow physician orders for obtaining blood pressures for Resident #68. In addition, the facility failed to follow physician orders for administration of a medication used to treat diabetes mellitus for Resident #29. Resident identifiers: #68 and #29. Facility census: 65.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure urinary catheter care was consistent with the professional standards of practice. This was true for one (1) out of three (3) residents reviewed for catheter care. Resident identifier: R#46. Facility census 65.

Inspectors wroteBased on record review and staff interviews, the facility failed to follow the pharmacist's recommendations and the physician order for one (1) of five (5) residents reviewed for the category of unnecessary medications during the long term care survey. Resident identifier #54. Census 65. Findings Included: a) Resident #54 Record review on 02/21/23 at 12:15 PM, discovered a consultation report scanned into the electronic medical record under the documents tab, recommending the monitoring of the resident's blood sugar for five (5) days and then to re-evaluate the use of the medication Onglyza and blood sugars. This consultation report was dated 01/17/23. A telephone order was placed in the resident's chart on 01/17/23 at 12:07 PM written as follows, Monitor blood sugar once daily at 0630 x 5 days then re-eval. Notify Physician if >300 or <70. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the daily staff posting included the actual hours worked by the licensed and unlicensed nursing staff and the number of staff directly responsible for resident care per shift. This had the potential to affect more than a limited number of residents. Facility census: 65.